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#130: Working out depression: Is exercise effective for depression?


CLINICAL QUESTION
QUESTION CLINIQUE
 Can exercise improve mild to moderate depression?

BOTTOM LINE
RÉSULTAT FINAL
 Exercise shows benefit in treating mild to moderate depression but the evidence is at a high risk of bias with smaller benefit in higher quality studies. In high quality studies showing benefit, approximately one in 8-12 patients with mild-moderate depression will attain remission due to exercise.   


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EVIDENCE
DONNÉES PROBANTES
 At least 10 systematic reviews have been done.1-10 Focusing on four of highest quality in depression [13-58 randomized controlled trials (RCTs), 720-2,982 participants, usually mild-moderate depression]:1-4 
  • Results in standard mean differences (SMD): A statistical tool to combine different scales with limited clinical meaning.   
  • Effect on depression compared to no treatment or control: Three meta-analyses found statistically significant improvements in depressive symptoms, ranging from “moderate” to “large” effects (SMD 0.6 to 1.1).1,2,4 Results inconsistent.  
    • In high quality studies:  
      • Using randomization concealment, intention-to-treat and blinded assessors: Two meta-analyses were no longer statistically significant.1,2  
      • Using only publication in peer reviewed journal/dissertation: Remaining analysis: SMD reduced from 1.1 to 0.7 (now a “moderate” effect).4 
    • Duration reduced effect from “large” (SMD=1.8) in studies <8 weeks duration, to “moderate” (SMD=0.6) if >8 weeks.4 
    • Exercise not statistically different from psychotherapy (seven RCTs, 189 patients) or medication (four RCTs, 300 patients).1 
    • Limitations: Many studies used patient self-report for results;1,4 small sample sizes; exercise was usually supervised/done in groups (therefore socializing could effect results);4 blinding, randomization concealment, and intention-to-treat infrequent. 
  • Examining the five highest quality RCTs:11-15 Three of five found statistically significant (or nearly): 11,12,15 
    • Response (≥30% reduction in Hamilton Depression score): Number Needed to Treat (NNT) 5 over 10 weeks.15 
    • Remission (“normal” Hamilton Depression score): NNT 8-12 over four months.11 
Context:  
  • Exercise has dose-dependent, positive effects on quality of life in non-depressed patients.16  
  • In chronic illness without depression, exercise has an inconsistent, small-moderate effect on depressive symptoms (SMD=0.3).9 
  • Largest effects of exercise were observed among those with mild-to-moderate depression.8 
    • Evidence is insufficient to judge if one type of exercise is better.3,4 

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Author(s)
Auteur(s)
  • Adrienne J Lindblad BSP ACPR PharmD
  • Doug Klein MD CCFP MSc
  • Shweta Dhawan BSc

1. Cooney GM, Dwan K, Greig CA, et al. Cochrane Database Syst Rev. 2013; 9:CD:004366.

2. Josefsson T, Lindwall M, Archer T. J Med Sci Sports. 2014; 24(2):259-72.

3. Rethorst CD, Wipfli BM, Landers DM. Sports Med. 2009; 39(6):491-511.

4. Lawlor DA, Hopker SW. BMJ. 2001 Mar 31; 322(7289):763-7.

5. Mura G, Carta MG. Clin Pract Epidemiol Ment Health. 2013; 9:125-35.

6. Bridle C, Spanjers K, Patel S. Br J Psych. 2012; 201(3):180-5.

7. Blake H, Mo P, Malik S, et al. Clin Rehabil. 2009; 23(10):873-87.

8. Sjosten N, Kivela SL. Int J Geriatr Psychiatry. 2006; 21(5):410-18.

9. Herring MP, Puetz TW, O'Connor PJ, et al. Arch Intern Med. 2012; 172(2):101-11.

10. Mura G, Moro MF, Patten SB, et al. CNS Spectr. 2014 Dec; 19(6):496-508.

11. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Psychosom Med. 2007 Sep-Oct; 69(7):587-96.

12. Blumenthal JA, Sherwood A, Babyak MA, et al. J Am Coll Cardiol. 2012 Sep 18; 60(12):1053-63.

13. Hoffman JM, Bell KR, Powell JM, et al. PM R. 2010 Oct; 2(10):911-9.

14. Krogh J, Saltin B, Gluud C, et al. J Clin Psychiatry. 2009 Jun; 70(6):790-800.

15. Mather AS, Rodriguez C, Guthrie MF, et al. Br J Psychiatry. 2002 May; 180:411-5.

16. Martin CK, Church TS, Thompson AM, et al. Arch Intern Med. 2009; 169(3):269-278.

Authors do not have any conflicts to disclose.